Transcript Power Point Slides (Arthur Rosner)

Rethinking Dizziness
The Role of Vision, Utricle, and
Saccule
Arthur Rosner, MD FACS
Debby Feinberg, OD
Mark Rosner, MD FACEP
John Kemink MD, 1949-1992
Shiro Fujita
Listen to the Patient
How it Started
Current Diagnosis

Failure to compensate
 Non-vertiginous dizziness
 Mal debarquement syndrome
 Mall patient
 Visual vertigo
 dyslexia
Current diagnosis

Vestibular Migraine
 Vomiting with anesthesia
 Motion sickness
 Central vertigo
 Neck pain
 Anxiety
Current diagnosis
Meniere’s Disease
 Agoraphobia
 Bilateral vestibular loss
 Vomiting on VNG

Prevalence

4% of my practice has binocular vision
dysfunction
 Over 8000 patients have been treated
 Optometrists now trained in other states
Vertical Heterophoria
A condition where one eye sees the image higher than
the other eye. The brain is intolerant of the unclear
image, and forces the eyes to attempt to create a clear
image. The strain on the visual system causes symptoms
that mimic conditions such as sinusitis, inner ear
disorders and migraines.
History

Von Graefe. A Uber musculaire Asthenopic. Arch
Opthal 1862;8:314-367.
 Doble J, Rosner M, Feinberg D, Rosner A ,
Identification of Binocular Vision
Dysfunction (Vertical Heterophoria) in
Traumatic Brain Injury Patients and Effects
of Individualized Prismatic Spectacle
Lenses in the Treatment of Postconcussive
Symptoms: A Retrospective Analysis2010
PMR 2010;2:244-253.
Transient Diplopia or Blurred
Vision
Thierry M. Using Prism Graphics. Detroit Free Press. August 2, 2005.
Symptoms
Dizziness
Headache
Head Tilt
Nausea
Agoraphobia
Anxiety
Motion sickness
Unsteady while
walking
Problems reading
Thierry M. Using Prism Graphics. Detroit Free Press. August 2, 2005.
Anxiety Symptoms Associated
with
Dizziness
 The
multiple objects in a large space can
overload the visual system and trigger a
dizzy episode. The resultant feeling is one
of being overwhelmed and anxious.
– Overwhelmed in big box stores, malls,
supermarkets, sports arenas, stadiums, theatres
– Anxious in crowds, school assemblies
Trigeminal nerve
Trigeminal nerve
Otolaryngology Examination
Head Tilt
Vertical and horizontal
disparity between the
eyes
Convergence
insufficiency
Duplication of
symptoms on eye
movements
Thierry M. Using Prism Graphics. Detroit Free Press. August 2, 2005.
Study Design

Otolaryngology examination
 Pre-treatment Vertical Heterophoria
Symptom Questionnaire (VHSQ)
 Optometry examination
 Eyeglasses with corrected prescription
including vertical and horizontal prism
 Post-treatment VHSQ
Inclusion and Exclusion
Criteria

100 patients sent for optometry evaluation
 60 patients seen by the optometrist
 39 patients filled out pre and post
questionnaires
 29 patients with vertical heterophoria
treated with prism
Demographics
Number of patients
from the study group
Female
25
Male
4
Prior prescription eyeglasses
25
Trouble adjusting to prior eyeglasses
9
Prior history of eye muscle imbalance or prior prism
4
Migraine history
7
Concomitant benign paroxysmal positional vertigo at initial
office visit, which resolved with Eply maneuver
4
Chief Complaint on
Presentation to the
Otolaryngologist
Number of
patients with a
chief complaint
of dizziness
Number of
patients with a
chief complaint
of sinus
headache
Number of
patients with a
chief complaint
of both
dizziness and
headache
At initial
presentation
16
7
6
Results from
questionnaire
before
treatment
7
1
21
Number of patients from the study
group
MRI of the head
8 All normal except for minimal
mucosal thickening
CT scan of the head
6 All normal except for minimal
mucosal thickening
Audiogram total
9
Audiogram normal
5
Bilateral symmetrical low frequency sensorineural
hearing loss
1
Bilateral symmetrical high frequency sensorineural
hearing loss
2
Asymmetric high frequency sensorineural hearing
loss with normal MRI
Elecronystagmogram total
6
Elecronystagmogram normal
4
Elecronystagmogram abnormal
2 abnormal optokinetic nystagmus
Optometry Evaluation
Functional
Vision Tests
Average Results
Range of Results
Expected
Findings
Vertical
Distance Phoria
.5PD base-up
left eye
0-1.5 PD base-up left eye
Ortho or 0
Vertical Near
Phoria
1PD base-up left
eye
1 PD base-down left eye-3.5PD
base-up left eye
Ortho or 0
Vertical
Vergence at
Near
4 PD/2PD base
up left eye
2PD/0PD base
down left eye
4PD/1PD base up left eye;
5PD/1PD base down left eye 7PD/4PD base up left eye;
2PD/0PD base down left eye
Break: 3-4
PD
Recovery:
1.5-2 PD
Trial Frame
Trial Framing

Dynamic process between patient and
doctor
 Quarter unit prism lenses are required
 Time needed between adjustments to allow
muscles in eyes and neck to relax
 Prescription modified based on the patients
response
 Needs to be learned in person
Prescription
Before
Treatment
After
Treatment
Patients with bifocals
10
27
Patients with myopia
18
19
Patients with hyperopia
5
9
Patients with astigmatism
18
27
Patients with glasses
25
29
Patients with vertical prism to correct a high left eye
and horizontal base-in prism
0
25
Statistics





Likert scale
0 = Never
1 = Occasionally
2 = Frequently
3 = always

Paired t-test before
and after treatment
 For each question
 Total questionnaire
score
Optometric Examination

Standard optometric exam
 Phoria testing, vertical vergence, and
Maddox rod tests do not predict the need for
prism, amount of prism or direction of
prism
Rank Question
P Value
Mean
difference
after
treatment
1
Do you experience dizziness, light-headedness, or nausea
associated with bending down then standing back up
quickly from a seated position?
< .0001
.8271
2
Do you blink to “clear up” distant objects after working at a < .0001
desk or with near centered tasks?
.8271
3
Do you feel unsteady with walking?
< .0001
.758
4
Do you tire easy with reading?
< .0014
.724
5
Do you experience poor depth perception or have difficulty
estimating distances accurately?
< .002
.62
Rank Question
P Value Mean
difference
after
treatment
6
Does print blur after reading a short time?
< .002
.62
7
Do you skip lines or lose your place while reading (using your
finger or other guide to maintain position on the page)?
< .002
.625
8
Do you tilt your head to one side when reading or working at a
desk?
< .002
.62
9
Do you experience dizziness, light-headedness, or nausea
< .0088 .552
associated with close-up activities (i.e., reading, writing, computer
work)?
10
Do you experience words running together with reading?
< .0090 .379
Rank Question
P Value
Mean
difference
after
treatment
11
Do you feel overwhelmed while walking in a large department < .0108
store (i.e., K-mart, Meijer)?
.552
12
Do you experience double vision or overlapping vision at far?
< .0136
.379
13
Do you experience blurred vision with close-up activities (i.e.,
reading, writing, computer work, sewing)?
< .0208
.552
14
Do you experience dizziness, light-headedness, or nausea
associated with far distance activities (i.e., driving, television,
movies)?
< .0252
.448
15
Do you experience blurred vision with far-distance activities
(i.e., driving, television movies, chalkboard at school)?
< .0298
.552
Rank Question
P Value
Mean
difference
after
treatment
16
Do you cover one eye while reading?
< .0365
.310
17
Do you have headache and/or facial pain?
< .053
.517
18
Do you hold reading material too close to your eyes?
< .0572
.345
19
Do you avoid close up tasks? (reading, writing, computer
work)
< .0668
.345
20
Do you experience double vision or overlapping at near
distance?
< .1095
.241
Rank Question
P Value
Mean
difference
after
treatment
21
< .3053
.172
Do you have pain in your eyes with movement?
Aggregate Results
Lowest Score
Highest Score
Average Score
Pre-Treatment
Questionnaire
Score
7
47
21.5
Post-Treatment
Questionnaire
Score
0
30
10.5
Difference in
questionnaire
score
Pre-treatment
to Posttreatment
11.0
P< .0001
Conclusions

Vertical Heterophoria is a syndrome
 Treatment with fractional units of horizontal
and vertical prism significantly reduces
patient symptoms p< .0001
 VHSQ seems to be a useful tool to identify
VH suspects and measure improvement
Symptoms Most Improved

Dizziness on bending down and standing up
 Blinking to clear up distant objects
 Unsteadiness when walking
 Fatigue with reading
 Poor depth perception
Vertical
Heterophoria in
Children
Pediatric Study Design

Retrospective study of pediatric patients
comparing and contrasting to adult
population
Pediatric Patient Analysis

2/16/05 thru 3/25/06
 33 children
– 9 lost to f/u
– 3 non-compliant (refused to wear glasses)

21 children with complete data
 7 yo – 17 yo, avg 10.4 yo
 11 boys, 10 girls
 8 previous eye glass wearers / 14 not
PMHx / ROS










Headaches = 14 pts
Dizziness = 7
Motion sickness = 6
Nausea = 6
Tires with reading = 6
Skips lines with reading = 6
ADHD / ADD = 5
Head tilt = 4
Double vision = 2
Anxiety = 2
Prescription Results

Farsighted = 17
 Nearsighted = 4
 Pediatricians only routinely test for
nearsightedness

20 out of 21 needed prism
 20 out of 21 needed bifocal
VHSQ Results

Pre-treatment VHSQ score avg = 17.9 (range 2-47)
 Post-treatment VHSQ score avg = 6.9 (range 1-17)
Normality tests – distribution of differences are
normally distributed
 Pre-treatment VHSQ is significantly higher than
post-treatment VHSQ score (p<0.0001, using
Student’s t-test)


Implies that treatment is effective
Vertical Heterophoria

Children and adults both have:
– Headaches and Dizziness as the primary
symptoms
– History of motion sickness
– Difficulty with near point tasks and
comprehension
Impact on School
Experience

Unable to maintain attention on near tasks
for prolonged periods:
– Computer and reading difficulty
Vertical Heterophoria
 Compared to
adults, children have:
– Lower VHSQ scores, Pre-treatment and post-
treatment
– Less need for spectacle prescription
modifications
– Less anxiety
– More farsightedness
Headaches
 “Head
hurts”
 Tend to be worse at the end of school days,
better on weekends
 Frontal, periorbital, temporal, crown,
occipital
Visual Causes of Dizziness





Riding in a car
Reading in a car
Swinging on swings
Spinning rides at fair
Postural changes
– Bending down and coming up quickly
– Standing quickly from seated or prone position
Problems With Depth
Perception

Binocular vision critical for depth perception
 Lack of binocularity causes symptoms:
– Feel klutzy and / or uncoordinated
– Walk into friends when walking beside them
– Fall often
– Difficulty with catching a ball
– Bumps into door jambs and furniture
Vertical Heterophoria in
Traumatic Brain Injury
Patients
Patients

83 patients sent for testing
 77 positive for vertical heterophoria
syndrome
 43 had complete data
Specialists Seen (78 patients):
3.25 specialists / patient
range: 0-9 specialists /
patient









IM or FP
Ophtho or Opto
Neuro
ENT
Chiropractor
PM&R
Psych
ER
Peds
64%
60%
47%
43%
35%
23%
21%
10%
0.5%
Tests Performed
1.27 tests / patient


Brain MRI
HCT

Audiogram
ENG
:
range: 0-4 tests / patient
43%
42%
– Pt had either had a HCT or MRI
– Had both HCT and MRI

(78 patients)
22%
21%
57%
27%
Top 10 Symptoms
VHSQ questions ranked by number of # of positive responders
AND frequency of symptoms:










(1) 3. Shoulder and neck discomfort
(2) 1. Headache
(3) 17. Glare / sensitivity to bright lights
(4) 4. Dizzy / lightheaded
(5) 8. Unsteady / drift to one side
(6) 11. Car rides = uncomfortable / dizzy
(7) 7. Dizziness with provocative head movements
(8) 13. Head tilt
(9) 20. Tire easily with close-up tasks
(10) 23. Blink to clear up distant objects
Retrospective Data Analysis
of 43 TBI Patients with VH
Retrospective
Avg
Age
Avg
Initial VHS-Q score
Avg
Final VHS-Q Score
Avg
Subjective % Improved
44
35
18.3
72%
(47.5% reduction)
M = 12
F = 31
Study 2:
TBI Study
1
2
3
6
Number of Patients
Mean Age (years)
Female Gender
Average duration of symptoms
(years)
Average duration of treatment
(months)
VHSQ Score (VH Symptom
Burden):
Initial
Final
Reduction with treatment
Average subjective
improvement with Prismatic
Lens Treatment using 0-100
numeric rating scale
(Subjective Improvement %)
43
44
72%
3.6 yrs
3.5 mos
34.8
18.1
48%
71.8%
Dizziness 2012

46 patients 2009-2011
 Chief complaint of dizziness
– Dizziness Handicap Inventory (DHI)
– Headache Disability Index (HDI)
– Zung Anxiety Scale (Zung)
– Vertical Heterophoria Symptom Questionaire
(VHSQ)
– 10 cm Visual Analog Scale (VAS)
Results 2012

DHI decreased by 51%
P<0.0001
 HDI decreased by 45%
P<0.0001
 VHSQ decreased by 50% P<0.0001
 Zung decreased by 22%
P<0.0001
 VAS decreased by 71% P<0.0001
Phoric Eye Posture in VH
Fovea
T
Orthophoria
Traditional
Vertical
Heterophoria
(CN4 / SO palsy)
*Vertical
Heterophoria
due to vertical
orbital
misalignment
*Vertical
Heterophoria
due TBI
*Optics not differentiated in the literature from Traditional VH (paradigm shift)
OS
OD
A
B
VH (A – orbital asymmetry) – Initial pathology
CN 4 / SO Palsy (B – CVA, tumor) – Initial pathology
affects both eyes
affects only 1 eye
Line of sight / phoric position of high eye is
depressed (Initial pathology)
Line of sight / phoric position of high eye is elevated and
extorted (Initial pathology)
Line of sight / phoric position of low eye is elevated
(Initial pathology)
Line of sight / phoric position of low eye is straight
ahead (normal) and intorted (Secondary pathology)
High eye sees high image
High eye sees low image
High eye is made even higher with head tilt*
High eye is made even higher with head tilt*
*Driving force is resolution of vertical diplopia
*Driving force is resolution of torsional / rotational
diplopia (still left with vertical disparity)
Utricle Dysfunction
Precipitating Events

Trauma
 Inner ear infection
 Eye surgery
 Mono-vision contacts
 Congenital
 Middle age
Utricle Dyfunction

Head tilt
 Vertical misalignment
 Ocular torsion
Superior semicircular canal

Works with utricle on vertcal eye posture
 SSCD Superior semicircular canal
dehiscence
Head Roll Tilt

Tilt to stabilize retinal image and reduce
diplopia
 Second most destabalized head posture after
head back
 Semicircular canals, otoliths, eyes are not in
proper alignment with gravity
 Change in center of gravity
Head Tilt

Destabilize balance and posture
 Inner ear and eyes not in normal plane
 Induction of vertical optokinetic nytagmus
on motion
Foot Posture

Feet position change with prism
 Toe in versus toe out
Vertical Eye Height Imbalance

30% of the population has one eye higher
than the other
 4% of the population has Vertical
Herterophoria
Retinal Slip





Eye misalignment and head tilt causes image to
be off center of fovea
Eye muscles are constantly trying to align images
Transient diplopia from muscle fatigue
Similar to meniere’s with a constantly changing
sensory input
Muscle pain mediated through V1 and V2
Visual Preference for Balance

Aldopho Bronstein
 Visual Vertigo
Motion Sickness

Vertical optico-kinetic nystagmus
 Associated roll tilt
 Combined with vertical eye skew
 Asymmetric optico-kinetic nystagmus in
time and angle
 Utricle dysfunction
 Visual preference for balance
Hierarchy of Balance

Staying upright
 Binocular vision
 Roll head tilt
 Ocular torsion
Menieres Disese of the eye

Fluctuation of visual image causes
symptoms
 Prevents compensation
 Translational vestibulo-occulo reflex vs
rotational vestibulo-occulo reflex
Feel like falling

Translational VOR
 Rotational VOR
 Switching between visual and vestibular
system
Medications

Neurology of eye movements, John Leigh,
and David Zee
Pathophysiology

Combination of: vertical misalignment of
the eyes, head tilt, utricle dysfunction, and a
visual preference for balance causes
symptoms
VNG findings

Pursuit
 Saccade
 Optiko-kinetic
 May have unilateral weakness or directional
preponderance
 Central vertigo
Vestibular evoked myogrenic
potential

Occular VEMP utricle
 Cervical VEMP saccule
 Stimuli tone or vibration
C-VEMP
O-VEMP
Saccule

Balance when supine or prone
 Autonomic dysfunction
 Postural hypotention
 Aging
 Pots Syndrome
Vestibular Therapy

Model from speech therapy
 Therapy targeted to VNG and VEMP test
results
Vestibular therapy

Utricle dysfunction
 Saccule dysfunction
 Pursuit abnormalities
 Saccade abnormality
 Optokinetic dysfunction motion sickness
 Caloric loss
Vestibular therapy

Roll tilt
 Leg lenth abnormality
 Pelvic assymetry
 Numbness of feet
 Low vison
Vestibular therapy

Hearing loss
Acute Vertical Heterophoria
Syndrome

Often associated with Benign paroxysmal
positional vertigo
 Can be associated with vestibular neuronitis
 Often hospitalized
 Treated differently
“Who, indeed, could have supposed that a mere
ocular defect could have given rise to so
serious a train of evils…and who that had not
seen it could believe that the correction by
glasses of the eye trouble could have given a
relief so speedy and so perfect that [the
patient] herself described it as a miracle?”
S. Weir Mitchell, Headaches and Eye Strain
April 1876 (13)
Thank you

Angie Mcnab (Lederman)
 Cheryl Wilson